Tracy Mansfield
Gallatin,TN
Summary
Clinical Compliance and Utilization Management professional with advanced expertise in CMS UM standards, NCQA requirements, audit readiness, and regulatory alignment. Licensed Speech-Language Pathologist with a strong record of data-driven clinical review, documentation accuracy, and policy interpretation across post-acute care settings. Known for delivering defensible, criteria-aligned determinations, maintaining 98–100% audit accuracy, and supporting organizations in meeting CMS, state, and contractual compliance expectations.
Overview
2027
2027
years of professional experience
1
1
Certification
Work History
Senior Therapy Case Reviewer
Carelon / Elevance Health
01.2021 - Current
- Conduct high-volume UM reviews for PT/OT/SLP services using CMS, Medicaid, and commercial payer policies, ensuring accurate, defensible medical necessity determinations.
- Maintain 98–100% audit accuracy through precise documentation, criteria alignment, and adherence to CMS and contractual requirements.
- Perform compliance-focused audits of expedited, standard, and specialty case types to ensure regulatory alignment and documentation consistency.
- Analyze clinical and operational data to identify trends, documentation gaps, and compliance risks; contribute to RCA and corrective action planning.
- Collaborate with medical directors and UM leadership on complex cases, policy interpretation, and workflow improvements.
- Support audit readiness by ensuring complete, timely, and CMS-aligned documentation across all case reviews.
- Adapt workflows and decision-making processes in response to CMS Final Rule updates, payer policy changes, and internal compliance requirements.
- Consistently exceed productivity, quality, and turnaround-time metrics across multiple regions and product lines.
Speech-Language Pathologist
Skilled Nursing & Rehab Settings
2011 - 01.2021
- Performed comprehensive evaluations and developed evidence-based treatment plans for adult and geriatric populations across SNFs and rehab settings.
- Ensured accurate, compliant documentation across multiple EMR systems, supporting audit readiness and regulatory alignment.
- Educated interdisciplinary teams on clinical findings, documentation standards, and care planning.
- Supervised CFY clinicians and graduate interns, ensuring adherence to clinical and regulatory expectations.
Education
MS - Speech-Language Pathology
Murray State University
BS - Communication Disorders
Murray State University
Skills
- CMS UM Standards & Regulatory Compliance
- Clinical Documentation & Audit Readiness
- Performance Measurement & Quality Metrics
- Medical Necessity Determination
- Prior Authorization & UM Case Review
- Workflow Optimization & Process Improvement
- Interdisciplinary Collaboration
- Case evaluation
- Professionalism and integrity
- Case information confidentiality
- Records management
- Issue identification and resolution
Certification
- CCC-SLP, ASHA
- Tennessee SLP License
- ESwallow NMES Certification
Timeline
Senior Therapy Case Reviewer
Carelon / Elevance Health
01.2021 - Current
BS - Communication Disorders
Murray State University
Speech-Language Pathologist
Skilled Nursing & Rehab Settings
2011 - 01.2021
MS - Speech-Language Pathology
Murray State University